Chest Pain

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Contents 1 More Specific Terms 2 Etiology 3 History 4 Clinical-manifestations 5 Laboratory 6 Diagnostic-procedures 7 Radiology 8 Differential-diagnosis 9 Management 10 More General Terms 11 Additional Terms 12 References

More Specific Terms

• pleurodynia
• Prinzmetal's angina; variant angina; coronary vasospasm
• stable angina pectoris (chronic stable angina)
• sternalgia (sternodynia)
• unstable angina (acute coronary syndrome, ACS)
• xiphoidynia (xiphoidalgia)

Etiology

• Cardiovascular

• myocardial ischemia

• pressure or squeezing pain
• radiation to left arm
• precipitated by exertion

• exercise
• meals
• emotion
• straining on defecation

• relieved by rest & nitroglycerin*

• Prinzmetal's angina
• myocardial infarction
• acute pericarditis

• steady, crushing, substernal pain
• pleuritic pain component aggravated by cough
• positional, relieved by sitting up

• valvular heart disease

• mitral valve prolapse
• aortic stenosis

• aortic dissection

• very severe pain, midline, radiation to back
• not affected by changes in position
• weak or absent peripheral pulses

• hypertrophic cardiomyopathy
• cocaine may induce acute myocardial infarction in young patients with normal coronary arteries

• Pulmonary

• pulmonary embolism

• pleuritic chest pain
• hemoptysis
• hypoxia
• tachycardia

• mediastinal emphysema

• sharp, intense, substernal pain
• audible crepitus

• pleurisy

• secondary to inflammation, less commonly tumor or pneumothorax
• generally sharp, unilateral, superficial
• aggravated by cough & respirations

• pneumonia
• tracheobronchitis
• lung cancer

• Esophageal pain: esophagitis, reflux, spasms

• dysphagia
• vomiting
• relieved by antacids

• Rheumatologic ( musculoskeletal)

• costochondral pain

• pain reproduced by pressure over painful area

• chest wall pain

• muscle or ligament strain from exercise
• rib fracture
• local tenderness

• fibromyalgia
• Tietze's syndrome ( costochondritis)
• arthritis: rheumatoid, osteoarthritis
• spinal disease
• subacromial bursitis

• Neurologic

• cervical or thoracic spine nerve root compression
• intercostal neuritis ( Herpes)

• Referred pain from abdominal disorders

• peptic ulcer
• hiatal hernia
• pancreatitis
• biliary colic
• colonic distension

• Inflammation or tumor of the breast
• Psychiatric disorders

• panic disorder
• anxiety
• phobias, especially agoraphobia
• depression
• somatization
• conversion
• malingering
• Munchausen's syndrome
• hyperventilation

• * relief of pain with nitroglycerin NOT helpful in establishing etiology [6,7]

History

• duration, location, radiation, character, intensity, rate of onset, relationship to activity, relief by nitroglycerin, rest, or antiacids, changes in frequency or severity of chest pain, occurrence during rest or sleeping, diaphoresis, nausea/vomiting, dyspnea at rest or on exertion, orthopnea, edema, palpitation, hemoptysis, dysphagia, cough, sputum, paresthesia, syncope, fever/ chills, use of cocaine effect of: inspiration, cough, position, arm, chest or neck movement, eating, NSAIDs, alcohol, exertion

Clinical-manifestations

• exertional chest pain suggests coronary artery disease
• non cardiac chest pain may coexist with coronary artery disease
• findings helpful in establishing diagnosis

• 4th heart sound
• systolic click
• murmur
• friction rub with pericarditis
• pain relief with change in position with pericarditis
• cardiac risk factors: smoking, hypertension, diabetes, hyperlipidemia
• chest pain occurring after meals or upon reclining suggests of gastroesophageal reflux
• cough or respiratory tract symptoms suggestive of pulmonary disease
• pain exacerbated by upper body movements in rheumatologic disease
• pain characteristics suggesting aortic dissection

• tearing or ripping sensation
• pain starting at maximum intensity
• radiation to back, abdomen or legs

• features associated with a low risk of cardiac ischemia

• age < 40 years
• no new ST segment changes on EKG
• pain reproduced by palpation
• radiation of the pain to the back, abdomen or legs
• a pain that is stabbing in nature

Laboratory

• complete blood count ( CBC)
• markers of myocardial infarction

• emergency department or inpatient setting

• erythrocyte sedimentation rate if indicated
• rheumatoid factor if indicated

Diagnostic-procedures

• electrocardiogram ( EGG)

• likelihood of an acute coronary syndrome in patients with chest pain & a normal ECG is the same whether or not chest pain was present when the ECG was obtained [9]

• stress tests

• graded exercise test with or without thallium or sestamibi scintigraphy
• dipyridamole thallium test
• exercise echocardiography

• psychometric testing if indicated

Radiology

• chest radiograph
• echocardiogram

Differential-diagnosis

• see etiology & also chest pain syndrome

Management

• directed at underlying etiology
• a normal physical exam, electrocardiogram, & laboratory results do not rule out coronary artery disease
• identification of emergency room patients with chest pain eligibile for early discharge [10]

• TIMI risk score = 0
• no new ischemic changes on electrocardiogram
• normal laboratory markers of myocardial infarction

• serum troponin-I
• serum creatine kinse MB
• serum myoglobin

• exercise testing before discharge not yet feasible in all hospitals
• patients with coronary artery disease should be followed periodically for an indefinite period to assess progression of disease
• most patients with chest pain & angiographically normal coronary arteries continue to complain of chest pain

More General Terms

• cardiology
• pain [odyn-]

Additional Terms

• chest pain syndromes

References

1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 5-6
2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 202-203
3. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 58-65
4. Chan & Winkle, Diagnostic History & Physical Examination, Current Clinical Strategies Publishing. Laguna Hills, 1996
5. Medical Knowledge Self Assessment Program (MKSAP) 11, American College of Physicians, Philadelphia 1998
6. Journal Watch 24(3):21, 2004 Henrikson CA et al, Ann Intern Med 139:979, 2003 PMID: &dopt=Abstract Gibbons RJ, Ann Intern Med 139:1036, 2003
7. Journal Watch 25(14):114, 2005 Diercks DB, Boghos E, Guzman H, Amsterdam EA, Kirk JD. Changes in the numeric descriptive scale for pain after sublingual nitroglycerin do not predict cardiac etiology of chest pain. Ann Emerg Med. 2005 Jun;45(6):581-5. PMID: [1]
8. Meyer MC et al, A critical pathway for patients with acute chest pain and low risk for short-term adverse cardiac events: Role of outpatient stress testing. Ann Emerg Med 2006; 47:427 PMID: [2]
9. Turnipseed SD et al. Frequency of acute coronary syndrome in patients with normal electrocardiogram performed during presence or absence of chest pain. Acad Emerg Med 2009 Jun; 16:495 PMID: [3]
10. Than M; Cullen L; Reid CM et al A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study The Lancet, Early Online Publication, 23 March 2011 <PubMed> PMID: [4] <Internet> [5]
    - Body R Acute MI: triple-markers resurrected or Bayesian dice? The Lancet, Early Online Publication, 23 March 2011 <PubMed> PMID: [6] <Internet> [7]
11. National Guideline Clearinghouse
    - Differential diagnosis of chest pain. (Finnish Medical Society Duodecim) ngc-guideline: [8]
    - Acute chest pain - no ECG or enzyme evidence of myocardial ischemia/infarction. American College of Radiology ngc-guideline: [9]
    - Acute chest pain-suspected pulmonary embolism. American College of Radiology ngc-guideline: [10]
    - ACR Appropriateness Criteria for chronic chest pain - high probability of coronary artery disease. American College of Radiology ngc-guideline: [11]
    - Chronic chest pain - low to intermediate probability of coronary artery disease. American College of Radiology ngc-guideline: [12]
    - Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. National Clinical Guideline Centre for Acute and Chronic Conditions ngc-guideline: [13]

chest pain